POLICY DEVELOPMENT, APPROVAL AND

Transcription

1 POLICY DEVELOPMENT, APPROVAL AND IMPLEMENTATION POLICY Ratification Process Lead Author: Developed by: Associate Director of Corporate Affairs CCG Secretary Directorate of Corporate Affairs Approved by: Policy Review Group Ratified by: Clinical Executive Committee Version: 3 Latest Revision date: Review date: February 2018 December 2019, or earlier if required by changes in local or national requirements Page 1 of 32

2 Document Control Sheet Development and Consultation: Policy developed to ensure consistent approach to policy development. The CCG Policy Review Group was involved in the original development and subsequent review of this document. Dissemination Implementation Training Audit Review Links with other Documents Equality and Diversity This policy is available to all CCG staff and independent contractors via the CCG website. Information about the policy was included in the staff and independent contractor newsletters The policy is used by all groups that develop, approve or ratify policies for the CCG. Formal training not required. A record of relevant policies is maintained by the Corporate Affairs Directorate including details of when a policy is due for renewal. The group approving each policy will use the checklist to ensure the policy meets the requirements of this policy. The Policy Review Group will review this policy every 2 years or sooner if significant amendments are made. The revised policy will be presented to the Clinical Executive Committee for it to review and approval The Policy should be read in conjunction with: Communications, Engagement and Membership Strategy The Directorate of Corporate Affairs has previously carried out an Equality and Impact Assessment on this Policy. This has been revisited as part of the latest review - with no changes required. Revisions Version Page/ Para No Description of change Date approved 1 Revised to meet changes in CCG structures November 2013 & July Document Control Sheet - Links with other documents updated 7 Duties and Responsibilities - updated Reference to the Policy Review Group added Policy Review Group ToR Added as Appendix 4 20 Equality Impact Assessment - Reviewed Throughout Updated to reflect latest changes in CCG committee and staffing structures Appendix 6 New Appendix 6 - implementation & dissemination plan template added Policies Group: CEC Policies Group: CEC Page 2 of 32

3 Table of Contents 1. Introduction 4 2. Purpose and Scope 4 3. Definitions 4 Type of document 4 4. Source of Document and Ratification Flowchart 5 5. Duties and Responsibilities 5 6. Developing the Strategy, Policy or Procedure 6 7. Document Control 6 8. Style and Format 7 9. Equality Impact Assessment Document Amendment, Review and Archiving Approval and Ratification Dissemination Implementation of Policies and Procedures Database 9 Appendices Appendix 1 Development, Dissemination and Implementation Flowchart 10 Appendix 2 Approval Checklist 11 Appendix 3 Policy Template 13 Appendix 4 - Policy Review Group Terms of Reference 18 Appendix 5 Equality Impact Assessment (EIA)Template 20 Appendix 6 - Implementation Plan Template 26 Appendix 7 - Completed EIA 30 Page 3 of 32

4 1. Introduction This policy aims to ensure a consistent and evidence based process for the development, approval and management of all Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) policies and procedures. 2. Purpose and Scope This policy sets out the responsibilities and requirements for developing, approving, ratifying and management of the CCG strategies, policies or procedures, for all CCG staff. 3. Definitions Type of document Strategy A strategy is a forward looking statement about the organisation s planned use of resources and deployment capabilities. It is a long term plan of action designed to achieve a particular goal. Strategy is about choice which affects outcomes and is adaptable by nature rather than a rigid set of instructions. Policy A policy is a strategic level document of what should be done in a particular circumstance, agreed by stakeholders. Policies do not allow for variation of practice. All policies must be approved and ratified. Some policies need to have final sign off by the CCG Governing Body dependant on the statutory requirements relating to the policy. Procedure/Protocol A procedure or protocol gives step by step guidance on how a policy is to be implemented. Whilst a policy sets out general aims and responsibilities, a procedure/protocol will state clearly who will do what and when. It is often included as the appendix to a policy. Procedures and protocols do not need formal Governing Body or sub-committee approval. They will either be agreed by local approval groups or as part of a policy. 4 Source of document and Ratification Flowchart A document ratification flowchart is set out below. Page 4 of 32

5 Type of policy Corporate - applicable to corporate governance, business and operational matters. These policies are generally approved by the Governing Body s sub committees and are ratified by the Governing Body Approved by (example groups other may also be agreed as Approval groups such as Local Commissioning Groups determining local policies) Clinical Executive Committee (CEC)) Ratified by CCG Governing Body Human Resources - applicable to all HR matters. HR policies are approved by the Clinical Executive Committee/ JCNP /Remuneration and terms of Service Committee and ratified by the Governing Body. Finance - Finance policy documents are approved by the Finance Committee and are ratified by the CCG Governing Body Any policy containing guidance relating to financial payments for good or services to NHS staff or contactors must include the Local Counter Fraud Specialist in development or review process Joint Consultation and Negotiation Partnership (JCNP) / Remuneration and Terms of Services Committee Finance Committee CCG Governing Body CCG Governing Body Equality & Diversity Policies CEC (via EDS Steering Group) CCG Governing Body IT & Information Governance - applicable to any information governance and IT issues, including data protection and records management. This also includes policies jointly developed by shared services requiring adoption in the CCG. Accounting Policies are approved by the Audit Committee and ratified by the Governing Body (includes Counter Fraud/Anti-Bribery policies IG, BI &IM&T Steering Group Audit Committee CEC CCG Governing Body Clinical, Quality and Patient Experience As a commissioning organisation the CCG do not require a significant number of clinical policies. However, some will be required in relation to clinical practice, quality and patient experience Quality Directorate Quality, Outcomes and Performance Committee (QOP) Medicines Management Joint Prescribing Group Clinical Executive Committee Page 5 of 32

6 Clinical Priorities Forum Policies Clinical Priorities Forum Clinical Executive Committee Research Governance Policies Implementation of national policies Research Governance Group Clinical Executive Committee Exceptional Cases Clinical Executive Committee CCG Governing Body Primary Care Commissioning Policies Primary Care Commissioning Committee CCG Governing Body / NHS England 5. Duties & Responsibilities Organisations are subject to a number of legal, statutory and good practice guidance requirements covering a wide range of subjects. In order to meet these requirements and to be able to demonstrate sound management within the constraints of existing legislation, it is necessary to have clear operational policies and procedures. The following specific duties and responsibilities apply within the CCG Acountable Officer - has overall responsibility for ensuring systems for all areas of policies and procedures are fit for purpose. CCG Governing Body - is responsible for final sign off regarding certain policies (see section 10). Director of Corporate Affairs has responsibility for overseeing the Policy for Policy Overview Group, which will be chaired by the Associate Director of Corporate Affairs (CCG Secretary). CCG Policies Group - Policies Group meets three times a year to review the Policy Database and monitor progress on the updating of existing or development of new policies. Teams developing policies & procedures - All CCG members and staff in developing policies and procedures are responsible for following the standards and guidance set out in this policy. Wherever possible patients should be represented in any development group. Advice relating to the design and review of documents in relation to systems weaknesses and countering fraud is available from the Local Counter Fraud Specialist. Approval Group - The development team or author must pass responsibility to a relevant group to approve the policy or procedure. This group must ensure an Equality & Diversity Impact Assessment has been carried out and action taken (see section 8 - Equality & Diversity Assessment). The group should check the document using the Policy Development checklist given in Appendix 2. They should check it is valid and relevant for its area of scope, that the document control is complete and that the format and spelling are correct. Governing Body Sub Committees designated sub groups of the CCG Governing Body with delegated responsibility to endorse relevant policies. Page 6 of 32

7 CCG staff are responsible for co-operating with the development and implementation of CCG policies and procedures as part of their normal duties and responsibilities. Temporay and Agency Staff, Contractors and Subcontractors - All temporary and agency staff, contractors and subcontractors will be expected to comply with the requirements of CCG policies and procedures applicable to their area of operations. 6. Developing the Strategy, Policy or Procedure A flowchart for the development of policies and procedures is given in the Appendix 1. This gives details of the questions to ask and processes to follow when developing or reviewing a policy. A template for the format and contents of the document is given in Appendix Document Control The front page of the policy or procedure must show the lead author, the group(s) that have approved and ratified it, the version number, the date it was ratified and the date it will be reviewed. Draft policies and procedures should clearly be annotated as draft. The second page of the policy or procedure must give document control details. These include: Development and consultation Dissemination Implementation Training Audit Review Links to other policies and/or procedures 8. Style and Format The following guidelines should be followed to make the document easy to navigate and read: Use simple, understandable English. Use a simple font such as Arial, with a font size of at least 12. Include a header or footer giving the name of the document and the date of implementation. Number sections and subsections so staff can easily refer to the relevant part of the document. Pages should be numbered, with page numbers and total pages, i.e. Page 5 of 16. For larger documents [i.e. greater than 4 main pages] use a table of contents to help navigation. Make use of bullet points to add clarity. Page 7 of 32

8 Documents should be left justified only. Fully justified documents are difficult for someone who is visually impaired to read. Additional information that enhances the complete document should be included as a numbered appendix, with reference to it within the text of the main document. The content will depend on the type of document and may include a flow diagram. When making references to documents, it should be possible to directly access the document referred whilst reading the main policy. This is done with the use of a hyperlink. 9. Process for Undertaking Equality Impact Assessment When a new policy is being developed, the approval group must complete an Equality Impact Assessment (EIA) to consider if a policy has a positive or negative effect on a particular group, and how this has been managed. The fact that the EIA has been carried out must be noted in the document control. It is essential that the assessment and any other evidence in relation to the assessment are retained as it may be required during inspection by a variety of agencies. The EIA template is attached at Appendix 5. The EIA form should be submitted to the Corporate Services Support Manager (Equality & Diversity) who will report the outcomes to the Equality and Diversity Steering Group, which is a sub group of the Clinical Executive Committee (CEC). The EIA must also be revisited when reviewing a policy. If major changes to the policy are anticipated, it may be necessary to complete a new EIA form. If in doubt advice should be sought from the Corporate Services Support Manager (Equality & Diversity). The Corporate Services Support Manager (Equality & Diversity) will assign a unique EIA number against each policy and which will be referenced in the CCG s Policies database. 10. Document Amendment, Review and Archiving Policies will be reviewed 2 years after ratification, or earlier if needed in the light of new evidence/legislation/guidance. Minor amendments that only change the administrative details of the policy or procedure only need to have the changes agreed by the approval group. This should be detailed in the Revisions section of the Document Control Sheet. The version number should be adjusted at the second level, i.e. version 2 would be amended to version 2.1. Amendments which alter the major processes of the document should be adjusted at the first level, i.e. version 2 would be amended to version 3. The document will then need to be ratified. It is essential that the version number and date on the front page, and in the footer, are also updated. When the new version of a document is ratified and disseminated, the old version is archived on the CCG shared drive. 11. Approval and Ratification A flowchart showing the route for ratification is set out in section 4 of this policy. Page 8 of 32

9 Approval The appropriate expert group will approve the content for accuracy, evidence base and using the best practice. It will complete an EIA using the policy development checklist The policy or procedure should be developed and approved by the relevant group. Ratification Final ratification of the policy is via the appropriate Governing Body Sub Committee, or the Governing Body itself. A flow chart showing the route for ratification is set out in section 3 above. Policies and Procedures/strategies need to go to the Governing Body when: They will have a major financial implication for the organisation [i.e. more than 100,000]. They are high level HR Policies, over which there is some local discretion [i.e. Grievance Policy, Disciplinary Policy]. They are multi-agency and cross cutting and will have a significant impact on the organisation [i.e. Community Strategy, Supporting People Strategy]. They may have a major impact on how CCG discharges its statutory responsibilities. The above list is not exhaustive and is only meant to give guidelines. If there is any doubt about whether a policy or strategy needs Governing Body ratification, advice can be sought from the Associate Director of Corporate Affairs (CCG Secretary). 12. Dissemination The dissemination process for the policy must be documented on the Document Control Sheet. It is the responsibility of the lead author to organise the dissemination of the policy. A template to support dissemination is set out at Appendix 6 On completion of the ratification process, the policy should be added to the CCG website. The Report Author should arrange for this to be done (advice can be sought from the Communications Team where required). If appropriate, details are included in the staff, or other, newsletters, or disseminated to the appropriate independent contractor groups. New and revised policies should be communicated via CCG Connect and where appropriate confirmation of receipt should be provided to the CCG Secretary. This would apply to key corporate policies such as the Health and Safety Policy and Risk Management Policy etc. where an implementation plan will be required. 13. Implementation of Policies and Procedures Compliance with policies and procedures is a requirement within employees terms and conditions set out in their contract. It is the responsibility of each line manager to seek guidance on the potential implications of a new policy on their area of responsibility. Where necessary the manager can arrange for an appropriate member of staff to give a briefing on the implications of the policy on their area of work. If an adverse event occurs, compliance with any relevant policies and procedures forms part of the investigation process. Page 9 of 32

10 14. The CCG has in place a Policies Group which meets three-times a year to review the Policy Database and monitor progress on the updating of existing or development of new policies. The membership comprises representatives from all Directorates. The Terms of Reference are attached at Appendix Database A database of CCG policies will be maintained within the Corporate Affairs Directorate. 15 Equality Impact Assessment The completed Equality Impact Assessment for this Policy has been reviewed and is set out at Appendix 7 16 Review This policy will be reviewed on a bi-annual basis, unless the need for an earlier review is identified. Page 10 of 32

11 Appendix 1 Development, Dissemination and Implementation Flowchart Agree Policy/Procedure to develop Agree Development Team Document Development Approval of Policy/Procedure Ratification of Policy/Procedure Disseminate and store Policy/procedure Implement and audit Policy/Procedure Review and update Policy What is the justification for developing the document? How does it fit with strategic plans/priorities? Are there existing policies that can be used?. Are resources available to implement the guidance of the document? The policy should be developed by a team representing all staff that will be involved in implementation. HR policies must have Staff Side/Union representation. Identify a lead author and who will be responsible for various aspects of the process. Involve patients and users in the process when relevant - if feasible is it possible to have a patient as part of the development team? Review national and local evidence, and relevant legislation. Use the policy template for guidance on development, style and formatting. Cross reference to other CCG documents where relevant All documents must include the a document control sheet The policy must be approved by an appropriate group within the CCG The group must check the policy against the approval checklist and the Equality Impact Assessment. There may be suggestions to the development group for changes to the document. The group should then ensure the policy is passed to the administrator for the appropriate ratification group. Identify which forum is the most appropriate to ratify the policy concerned CCG Governing Body sub Committee / Joint Consultation and Negotiation Partnership (JCNP) etc. It is the responsibility of the lead author to organise dissemination and to (1) communicate via Connect; and (2) published on the CCG website (3) advise the Corporate Affairs Directorate. The Corporate Affairs Directorate will have responsibility for maintaining the policy database. The document development team should lead on the agreed implementation plan, including training and audit. Refer to template at Appendix 6 When reviewing the policy: Ensure the updating process includes an evidence review and consideration of any patient views collected since the last review. Include details of review process in the updated document. Page 11 of 32

12 Appendix 2 Approval Checklist This form should be used by the Approval Group to ensure the policy meets the agreed requirements. Use and results of the checklist should be minuted. Title of Document Approval Group Date of Check 1. Basic Details Is the title clear and unambiguous? Is it clear if it is a guideline, policy, protocol or procedure? Is the authorship clear? Is the document clearly dated? Is the document control sheet complete? Yes No N/A Comments 2. Rationale Are reasons for developing the document clearly stated? 3. Development Process Is the method described in brief? Are the people involved in the development identified? Were all relevant parties involved in the development? Is there evidence of consultation with stakeholders and users if appropriate? 4. Content Is the objective of the document clearly stated? Is the scope identified e.g. patients and/or staff? Are the intended outcomes described? Is the guidance clear, relevant and unambiguous? Has a Equality Impact Assessment been completed Page 12 of 32

13 5. Evidence Base Is evidence to support the document identified? Are key references given? Yes No N/A Comments Are appendices relevant? 6. Summary of Guidance Is there a quick reference guide, key recommendations or flowchart summarising the document if appropriate? 7. Format Is the document in an easily readable font? Is there an appropriate header or footer on each page? Is it easy to find sections within the document? 8. Dissemination and Implementation Is there a dissemination plan? Is there an implementation plan, including training and audit? 9. Review Is the date of review stated? 10. Any comments or changes needed Policy approved: Yes / No Page 13 of 32

14 Appendix 3 Policy Template Red text is for guidance and should be deleted as document is completed Ratification Process Lead Author Developed by Approved by Ratified by Version Latest Revision date Review date Policy Title Page 14 of 32

15 Document Control Sheet Development and Consultation: Dissemination Implementation Training Monitoring Review Links with other documents Equality and Diversity Give details of the team that developed the policy, any patient involvement and the group that approved the document Give details of how the policy will be disseminated to and how this will happen Give details of which group is responsible for implementation Give details of any training required and who needs the training, or indicate if no training required How and where compliance with the policy will be monitored, audited, and by whom Who is responsible for reviewing the policy The policy should be read in conjunction with: Give details of any other linked documents, or delete if not linked documents The XXXX has carried out an Equality Impact Assessment and concluded the document is compliant with the CCG Equality and Diversity Strategy. Add details of the individual or group which carried out the Equality and Diversity Impact Assessment and any actions taken. Revisions Version Page/Para No Description of Change Date Approved When you change the version, remember to update the front cover and footer version number and date. Double click on the footer to access the footer and footer toolbar. Page 15 of 32

16 Contents 1. Introduction Purpose and Scope Duties and Responsibilities Guidance Other Sections Statutory and other Relevant Guidance References Appendix - Title To add a Table of Contents for your headings, go to Insert, Index and Tables. To update the Contents page, right click within the grey area, choose Update Field. If you get another option, choose Update entire table. Page 16 of 32

17 1. Introduction State the reason for developing the document, for example: to enable healthcare professional to recognise and respond effectively to this is area of high volume activity and high cost to support nurse prescribing for 2. Purpose and Scope Give details of: Objective[s]: Clearly state what the document is intended to achieve Intended Outcome[s]: What are the intended benefits for patients and staff State who the guidance is intended for, both who will use the guidance and who it will be used for i.e. which patient/staff groups. 3. Duties and Responsibilities State the responsibilities of staff at various level in implementing the document. The following specific duties and responsibilities apply within the CCG: For example:- Governing Body Members Directors Senior Managers Team leaders CCG Staff Local Commissioning Groups etc. Add or delete as necessary. 4. Guidance Add the main content of the document here. These sections form the main part of the document. Use clear headings, sections and subsections to make the document easy to navigate. Ensure the guidance addresses the objectives, outcomes and target population, and all areas of relevant practice. If the document refers to a form, flowchart, patient information leaflet etc, include these as appendices wherever possible. Cross reference to other CCG policies or documents as appropriate. Other Sections Statutory and other Relevant Guidance Give details of any statutory, national or other relevant guidance that has been used to develop this document, e.g. This document meets the requirements of level of the Risk Management Standards for CCG?. References Any documents referred to within the document must be listed, giving the author[s], title, publication source and date.appendix - Title If you have appendices, add the title as directed. This will be added to the Contents page. Page 17 of 32

18 Appendix 4 Policy Review Group Terms of Reference 1. Purpose The Policy Review Group will review the Policy Database and monitor progress on the updating of existing or development of new policies for Cambridgeshire and Peterborough Clinical Commissioning Group. The Group will also ensure polices are compliant with any new or revised statutory duties relevant to the CCG. 2. Membership Deputy Director of Corporate Affairs (Chair) Head of HR and OD (Deputy Chair)Senior ICT Service Development Manager Corporate Services Support Manager (Equality & Diversity) Corporate Services Support Manager (Information Governance) Governance Support Manager (s) from Directorate as follows: - Nursing and Quality - Complex cases - Nursing & Quality - Medicines Optimisation - Primary & Planned Care - Exceptional Cases & Clinical Policies Finance Other Directorate representatives as required. 3. Frequency The Policy Review Group will meet three times per annum. Meetings will be arranged with Teleconference facilities. The Chair (or in their absence the Deputy Chair) will have the option to convene additional meetings if and when required. 4. Key Objectives 4.1 To review the Policy Database on a regular basis and to ensure that policies are updated in line with their Revision Dates. 4.2 To ensure consistency of all Policies across the CCG and that they are developed in the appropriate format. 4.3 To share good practice in developing policies and procedures. Page 18 of 32

19 4.4 To ensure all policies have an Equality Impact Assessment and that these are updated on a regular basis. 4.5 To have oversight on the implementation of new and revised policies as where appropriate 5. Reporting 5.1 Action notes will be taken at each meeting and reviewed by the Governance Support Manager. 5.2 The Policy Review Group will report to the Clinical Executive Committee on an exceptions basis. 6. Review These Terms of Reference will be reviewed on an annual basis. Sharon Fox Deputy Director of Corporate Affairs Approved by: Date: XX Clinical Executive Committee Page 19 of 32

20 APPENDIX 5 Equality Impact Assessment - Template Name of Proposal (policy/strategy/function/service being assessed) Those involved in assessment: Is this a new proposal? Date of Initial Screening: What are the aims, objectives? Who will benefit? Who are the main stakeholders? What are the desired outcomes? What factors could detract from the desired outcomes? What factors could contribute to the desired outcomes? Who is responsible? Have you consulted on the proposal? If so with whom? If not why not? Which protected characteristics could be affected and be disadvantaged by this proposal (Please tick ) Age Consider: Elderly, or young people Yes No Disability Gender Reassignment Marriage and Civil Partnership Consider: Physical, visual, aural impairment Mental or learning difficulties Consider: Transsexual people who propose to, are doing or have undergone a process of having their sex reassigned Consider: Impact relevant to employment and /or training Page 20 of 32

21 Pregnancy and maternity Race Religion and Belief Sex /Gender Consider: Pregnancy related matter/illness or maternity leave related mater Consider: Language and cultural factors, include Gypsy and Travellers group Consider: Practices of worship, religious or cultural observance, include non-belief Consider: Male and Female Sexual Orientation Consider: Know or perceived orientation What information and evidence do you have about the groups that you have selected above? Consider: Demographic data, performance information, recommendations of internal and external inspections and audits, complaints information, JNSA, ethnicity data, audits, service user data, GP registrations, CHD, Diabetes registers and public engagement/consultation results etc. How might your proposal impact on the groups identified? For example you may wish to consider what impact it may have on our stated goals: Improving Access, Promoting Healthy Lifestyles, Reducing Health Inequalities, Supporting Vulnerable People Examples of impact re given below: a) Moving a GP practice, which may have an impact on people with limited mobility/access to transport etc. b) Planning to extend access to contraceptive services in primary care without considering how there services may be accessed by lesbian, gay, bi-sexual and transgender people. c) Closure or redesign of a service that is used by people who may not have English as a first language, and may be excluded from normal communication routes. Please list the positive and negative impacts you have identified in the summary table on the following page. 1 Summary Positive impacts (note the groups affected) Negative impacts (note the groups affected) Summarise the negative impacts for each group: Page 21 of 32

22 What consultation has taken place or is planned with each of the identified groups? What was the outcome of the consultation undertaken? What changes or actions do you propose to make or take as a result of research and/or consultation? Briefly describe the actions then please insert actions to be taken on to the given Improvement Plan template provided. Will the planned changes to the proposal: Please state Yes or No Lower the negative impact? Ensure that the negative impact is legal under anti-discriminatory law? Provide an opportunity to promote equality, equal opportunity and improve relations i.e. a positive impact? Taking into account the views of the groups consulted and the available evidence, please clearly state the risks associated with the proposal, weighed against the benefits. What monitoring/evaluation/review systems have been put in place? When will it be reviewed? Date Review completed: Signature: Approved by: Page 22 of 32

23 Date approved: Please refer to Improvement Plan template overleaf to take forward actions identified. Page 23 of 32

24 Equality Impact Assessment Improvement Plan name of proposal Area of Negative Impact Changes Proposed Name of Lead Timescale Resource Implication Comments Date: Lead: Page 24 of 32

25 Appendix 6 IMPLEMENTATION & DISSEMINATION PLAN - TEMPLATE Dissemination of a new or revised Policy ACTION BY ACTIONS - NEXT STEPS STATUS Lead author to discuss with relevant parties and organise dissemination of policy Include date when action needs to be completed Progress on actions Confirm status - e.g. in progress / Completed / - Identify who the policy is aimed at (all staff / certain staff or teams / GPs etc. overdue etc. - produce a briefing note for the various staff groups - where necessary. Highlight purpose of policy and why relevant to recipients - Arrange for the Policy to be published on the CCG website - Communicate policy via iconnect - liaise with communication team to do this CAPCCG.contact@nhs. net - Inform the Corporate Page 25 of 32

26 Governance Team once policy has been published - so that the policies database can be updated. Briefing and Awareness Sessions / Training (Where identified as being needed) ACTION BY ACTIONS - NEXT STEPS STATUS Arrange for any necessary briefing or training sessions to support the use of the new or revised policy This could include briefings to Lay Members, Sub Committees and other relevant staff group or team meetings. Consider if appropriate to raise awareness of the policy via the periodic staff briefings arranged by the Communications Team Briefing to Member Practices - if required (e.g. Member Practice Events) Page 26 of 32

27 Arrange further or refresher briefing sessions after a set period (if required) If requirement for training is Mandatory - liaise with HR around the requirements for this. It will be necessary to ensure it is included in the staff appraisal process paperwork. Audit, Administration and Review ACTION BY ACTIONS - NEXT STEPS STATUS Consider if periodic review of policy and/its use/outcomes is required(in addition to - if required Internal Audit Review - consider if necessary for future assurance Consider if necessary to provide periodic progress reports on policy use/outcomes to any formal committee e.g. Clinical Executive Committee Does it needed to be included as part of the CCG s Corporate Page 27 of 32

28 Induction and Induction Pack Does it need to be included or embedded into the CCG s Recruitment Processes - liaise with HR Page 28 of 32

29 APPENDIX 7 Equality Impact Assessment Name of Proposal (policy/strategy/function/service being assessed) Those involved in assessment: Policy Development, Approval and Implementation Policy CCG Secretary, Corporate Governance Team Is this a new proposal? Updated PCT policy Date of Initial Screening: 19 September 2013 Reviewed August 2017 What are the aims, objectives? To ensure a consistent approach to policy development and approval is adopted throughout the CCG Who will benefit? The CCG Who are the main stakeholders? CCG managers and staff. What are the desired outcomes? To secure a consistent approach to policy review, development and approval. What factors could detract from the desired outcomes? Lack of awareness and/or non-enforcement of the policy. What factors could contribute to the desired outcomes? Awareness raising of the Policy via the CCG Website. Who is responsible? Have you consulted on the proposal? If so with whom? If not why not? Director of Corporate Affairs Policy developed with the Policies Review task and Finish Group which included representatives from different Departments/sections Page 29 of 32

30 Which protected characteristics could be affected and be disadvantaged by this proposal (Please tick ) Age Consider: Elderly, or young people Yes No Disability Gender Reassignment Marriage and Civil Partnership Pregnancy and maternity Race Religion and Belief Consider: Physical, visual, aural impairment Mental or learning difficulties Consider: Transsexual people who propose to, are doing or have undergone a process of having their sex reassigned Consider: Impact relevant to employment and /or training Consider: Pregnancy related matter/illness or maternity leave related mater Consider: Language and cultural factors, include Gypsy and Travellers group Consider: Practices of worship, religious or cultural observance, include non-belief Sex /Gender Consider: Male and Female Sexual Orientation Consider: Know or perceived orientation What information and evidence do you have about the groups that you have selected above? N/a Consider: Demographic data, performance information, recommendations of internal and external inspections and audits, complaints information, JNSA, ethnicity data, audits, service user data, GP registrations, CHD, Diabetes registers and public engagement/consultation results etc. How might your proposal impact on the groups identified? For example you may wish to consider what impact it may have on our stated goals: Improving Access, Promoting Healthy Lifestyles, Reducing Health Inequalities, Supporting Vulnerable People Examples of impact re given below: d) Moving a GP practice, which may have an impact on people with limited mobility/access to transport etc. e) Planning to extend access to contraceptive services in primary care without considering how there services may be accessed by lesbian, gay, bi-sexual and transgender people. Page 30 of 32

31 f) Closure or redesign of a service that is used by people who may not have English as a first language, and may be excluded from normal communication routes. Please list the positive and negative impacts you have identified in the summary table on the following page. 2 Summary Positive impacts (note the groups affected) N/a Negative impacts (note the groups affected) N/a Summarise the negative impacts for each group: N/a What consultation has taken place or is planned with each of the identified groups? N/a What was the outcome of the consultation undertaken? N/a What changes or actions do you propose to make or take as a result of research and/or consultation? Briefly describe the actions then please insert actions to be taken on to the given Improvement Plan template provided. N/a Will the planned changes to the proposal: Please state Yes or No Lower the negative impact? Ensure that the negative impact is legal under anti-discriminatory law? Provide an opportunity to promote equality, equal opportunity and improve relations i.e. a positive impact? N/a N/a N/a Taking into account the views of the groups consulted and the available evidence, please clearly state the risks associated with the proposal, weighed against the benefits. N/a Page 31 of 32

32 What monitoring/evaluation/review systems have been put in place? Overview by CCG Secretary and Policies Task and Finish Group When will it be reviewed? August 2019, or earlier if required by changes in local or national requirements. Date completed: Original Review completed 9 March Reviewed: 17 August 2017 Signature: Approved by: Simon Barlow Sharon Fox Date approved: (Original) 9 March 2016 (Review) 17 August 2017 Page 32 of 32